Emergency Departments; Tackling Complex systems on the Edge of Chaos

Emergency Departments; Tackling Complex systems on the Edge of Chaos

Emergency Departments have a well earned reputation for being pretty busy places to work.
For some Emergency Physicians, the conditions worked in provide a constant challenge, for others where there have been significant improvements in recent years, patient attendances continue to increase. A reflection that Emergency Departments offer the only 24/7 front door to many healthcare systems, where pressure continues to mount..

EM Challenges: Simple/Complicated/Complex/Chaos

While the environment we work in occasionally presents simple challenges, Emergency Departments are very familiar with complicated clinical cases, indeed juggling several such patients at the same time makes it the complex environment we take for granted. We will also be familiar with shifts that quickly change, testing the whole team, when Emergency Departments move to the “edge of chaos”. While the range and variety of challenges that present themselves to us in EDs and the perpetual novelty can be part of the reason we enjoy working in Emergency Medicine, this complexity is not always enjoyable and at times our brains must struggle to cope.

So how can we make sense of the Emergency Departments we work in, knowing the same place can go from a quiet tranquil shift on a weekday morning, to a pretty crazy place within a couple of hours? As part of the education I’ve been fortunate to have gained in Emergency Medicine, I’ve learned that looking for patterns amidst complex systems is key to making sense of our challenges… so let’s look at some of the common patterns that come to mind and see whether this resonates..

Patterns in Emergency Medicine

If looking for key patterns with the complex adaptive systems that are Emergency Departments, what are the key patterns you see and the key elements for a good shift? If we can explore some of those common patterns & elements, we may be better placed to lead our teams, improve our care and support our patients better.

As I look I see 3 key patterns amidst our environment, related to People, Process and Technology.

Most all of us have significant People challenges in Emergency Medicine; How to recruit the best staff? Best means to train them to be excellent Emergency Physicians and Healthcare Leaders? How to support staff when things (inevitably) go wrong. Importantly how to retain staff amidst the pressure and challenge of EM.

From a Process perspective, most of us would admit there is significant room for improvement at the clinical frontline, no matter where we work, there is and will be always ways to do things better. As a result many Emergency Departments actively engage in process improvement efforts, via clinical audit, lean thinking and or other approaches. Once started such efforts offer a never ending cyclical need for refinement and further improvement

Thirdly the information we gather and/or record about our patients is often a time-consuming and inefficient element of the patient-physician encounter. The Technology we rely on often does not fit well with our complex process and so can become part of the problem, rather than the solution. Equally the related knowledge base that informs our practice (i.e. the evidence behind what works and what doesn’t) in many important clinical areas can be difficult to keep on top of/ access when we need it, so these “tools” also need to be improved.

Working Smarter>Harder

As much of the pressure within Emergency Medicine lies on the shoulders of Emergency Physicians…. the pressure of increased attendances, search for greater efficiency, safety and effectiveness within Emergency Departments continues to mount and take its toll.

Yet as Emergency Medicine moves forward, the likelihood of increasing frontline pressure in the future should not simply involve asking the EM workforce to “work harder”. We must increasingly look for ways to “work smarter” rather than harder- to improve Emergency Medicine, to support our staff and improve our processes of care. From my perspective working between Emergency Medicine and Informatics for the last 10 years, I have no doubt that further improvements in information management and technology will be key and critical to success to the future of Emergency Medicine.

Over the next couple of months leading up to the ICEM 2012 meeting in Dublin I’ll be looking in more detail at the current state of information management in Emergency Medicine, looking at areas where we are strong and others areas where major change is needed.

Take for instance the typical patient journey in the Emergency Department, have you considered it can be considered “information intensive”? Do you see room for improvement as you talk to your patients/ examine them/ establish their differential diagnosis and related management plan? Are you/how are you able to keep on top of the EM literature and ensure all your care is evidence based? Are your patients happy with their care? Do you measure it?

Then think about the last clinical audit that you did. Can you recall any of the top recommendations? Did improvements in documentation, clinical data capture etc feature anywhere there?
If you manage an Emergency Department, do you find a tension and challenge in measuring and monitoring the timeliness, quality and safety of care in your department, aware that such efforts might be adding to the burden at the frontline?

Perhaps you have an academic interest? You may be involved in a clinical research area. Have you been struggled to recruit patients into a frontline research study and/or found research study documentation just a little bit more hassle than you needed on that late shift?

One Key to the Future

Over the course of several related articles, I’m hoping to show that while EDs are sometimes on the edge of chaos, that understanding and embracing the complexity of our environment is key to success within Emergency Medicine and indeed across the breadth of healthcare.
With a look at some of those common core processes that underpin our work I’ll be making a case that better information technology is key to the future of Emergency Medicine. While such an assertion is not news to our specialty, I’ll be exploring and explaining why related developments have not kept pace with the world around us and why some of us need to be more actively involved and look to collaborate to make things better.

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interesting post
St Vincents has for the past few years been on the pathway (sucessfully) towards and through JCI accreditation. The focus on documentation has been an internal driver that seems to be having an effect on the trainee doctor population- a group that are transient through the hospital system. One the years we have noticed a significant improvement in note taking and clarity in our records….this has occured mainly as a culture change. One would love to say that it is as a direct result of education but I fear not as our education efforts are sporadic. However, measurement of hospital documentation through multiple audits (including simple ED ideas like putting the clinical interpretation and time thereof, on ECGs) has paid off.
It emphasises the effect of culture on behaviour and how effective this can be in inculcating behaviours without explicit intervention

Changing medical documentation is an interesting way to effect change.

As you know, we doctors tend to write a fair bit. Much of it for good reason, helps to structure our subjective and objective assessment of the patients problem. As per Larrys Weeds SOAP approach, this can/should lead onto assist with the decision making process and related planning (the A&P in SOAP).

So in some ways the documentation directly influences/assists our clinical reasoning and structures our thinking .. for better or for worse.
Its also aimed at clinical correspondence purposes, to enable handover to the next care provider in the patients journey..
Of course a medico-legal record which could/should be usable for research and audit are other by-products..
Yet I think most of us would admit there is major room for improvement in how we document in the ED (which should have other related improvements to accompany that change).

It would be interesting to know who if anyone led the cultural aspect of the change you describe?

frectal

frectal is a place for to share some thoughts and ideas in a complex world.
Interests include healthcare, change, leadership, quality improvement, information systems, standards and the value of simple rules in a complex world
I hope some of these thoughts are helpful to others.